Beyond Tear Trough Filler: The Modern Toolkit for Under-Eye Rejuvenation

Beyond Tear Trough Filler: The Modern Toolkit for Under-Eye Rejuvenation

By Alice Henshaw, RN, NMP, Founder and Medical Director, Harley Street Injectables

Key Takeaways

• Tear trough filler is one tool among many. For a significant proportion of clients, it is not the right first choice. Before you decide on a treatment, get a diagnosis. Our companion article, A Practitioner’s Guide to Understanding and Treating Hollow Eyes, explains the five presentations of under-eye ageing in detail.
• Polynucleotides are the single most useful non-filler option for most under-eye concerns. A randomized split-face trial by Lee et al. (2022) in Journal of Dermatological Treatment compared polynucleotide injections directly against hyaluronic acid filler in the periocular area, and polynucleotides showed higher improvement in skin elasticity, roughness and pore volume over time.
• For crepey skin and fine periorbital wrinkles, radiofrequency devices like Thermage FLX have strong published evidence. The landmark multicenter study by Fitzpatrick et al. (2003) in Lasers in Surgery and Medicine reported that a single treatment improved periorbital wrinkle scores in 83.2% of treated areas (99/119) with a 2nd-degree burn incidence of just 0.36%.
• Under-eye rejuvenation is rarely a single-treatment job. At Harley Street Injectables, we regularly combine polynucleotides, skin boosters, RF tightening, and (sometimes) a small, conservative amount of tear trough filler across a phased plan. The goal is never more treatment. It is the right treatment, in the right order, in the right amount.
• If you have been told you are not a filler candidate, you are not out of options. For thin skin, fat pad puffiness, vascular darkness, or previous poor filler outcomes, we now have five or six tools that work better than filler. This article is about choosing between them.

Most articles about the under-eye area start with “should you get tear trough filler?” I want to start somewhere else.

I want to start with a client I saw last month. She came in asking, specifically, for tear trough filler. She had read about it. Her friend had it done. She had done her research. And she was wrong, in the most well-meaning way a client can be wrong, about what her face actually needed.

Her under-eye darkness was almost entirely vascular, caused by thin translucent skin^{1Translucent skinSkin thin enough that the blood vessels beneath show through, creating a bluish or purplish shadow that filler cannot fix.} letting the underlying blood vessels show through. There was almost no structural volume loss. If I had filled her tear troughs, I would have created a mild puffiness above an unchanged shadow, and she would have left the clinic looking worse than she arrived, and paid a meaningful sum of money for the privilege.

Instead, we started her on a course of polynucleotides^{2PolynucleotidesInjectable DNA fragments that regenerate skin from within.}. Three sessions, three weeks apart. At her six-week review, the darkness had reduced noticeably and, critically, without adding any volume. She did not need tear trough filler. She never did.

I wanted to open with that story because it captures the thesis of this article. The under-eye area has, until recently, been treated as if it had one problem and therefore needed one solution. That solution was filler. For some clients, filler is genuinely the right treatment, and when it is, the results can be transformative. But a decade of treating this area, and doing a great deal of corrective work on clients who have had filler elsewhere, has taught me something I want more patients to understand before they book anything.

Under-eye hollowing is not one thing. It is five or six different things, often layered on top of each other. Each one has a best treatment, and filler is the best treatment for only one of them.

If you have read our Practitioner’s Guide to Understanding and Treating Hollow Eyes, you will already know the framework I use for diagnosing the under-eye area, which separates the five presentations of under-eye ageing (true volume loss, skin thinning and vascular shadowing, fat pad herniation, pigmentation, and the combination presentation most people actually have). That article is the “what is wrong” piece. This one is the “so what are my actual options” piece. Because knowing you have vascular shadowing is only half the battle. You then need to know which of the available tools is best suited to it, and why.

Think of this as the modern toolkit, laid out honestly. I will walk through each option, what it does, what the published evidence says about it, who it is right for, and who it is wrong for. I will give you a decision framework at the end to help you orient yourself before a consultation. And I will be honest throughout about the trade-offs, because every one of these treatments has them.

Why I Am Writing This Now

Five years ago, when a client came to me with under-eye concerns, I had roughly three tools to offer: tear trough filler, cheek filler to support the mid-face, and a referral to a surgeon for blepharoplasty in cases where non-surgical options were not appropriate. That was more or less it.

That toolkit has expanded considerably. Polynucleotides arrived in the UK properly around 2022 and have become, for the under-eye area specifically, one of the most transformative additions I have seen in my career^{3PDRN/PNPolydeoxyribonucleotides and polynucleotides, DNA fragments that stimulate the skin’s own regenerative cells.}. Skin boosters like Profhilo and Skinvive by Juvéderm give us hydration-forward options that sit somewhere between a traditional filler and a polynucleotide, with different biological mechanisms and different indications. Non-invasive skin-tightening devices, particularly Thermage FLX and NeoGen Plasma, can improve periorbital laxity and texture in ways that injectables alone cannot. Morpheus8 adds radiofrequency microneedling to the periorbital repertoire for select cases.

We now have a genuine toolkit. The question has shifted from “filler or not?” to “given your specific presentation, which of these six or seven options is the best first step, and how do we sequence the rest if you need more than one?”

This has been good news for patients. But it has introduced a new problem, which is that most content online has not caught up. The tear trough filler articles are still dominant. The polynucleotide articles mostly talk about PN as if it were a standalone treatment for skin quality, without putting it into the decision framework that a practitioner would actually use. And the device options (Thermage, NeoGen, Morpheus8) get almost no airtime in the under-eye conversation at all, even though for certain patients they are clearly the right starting point.

I want this article to be the thing that fills that gap. Not a brochure for any one treatment, including the treatments we perform, but an honest map of the territory.

The Decision Framework: What Are We Actually Treating?

Before we talk about tools, let me briefly recap what we are choosing between, because the toolkit only makes sense in the context of what it is treating.

When a client sits in front of me in consultation, my first job is to separate their visual concern into its underlying causes. “Dark circles,” as a reported symptom, can be caused by any of five or six distinct anatomical changes, and the treatment depends entirely on which cause is dominant.

The main presentations, which I cover in detail in the Hollow Eyes article, are:

1. True volume loss, where fat pads and bone have receded, creating a genuine structural trough.
2. Skin thinning and vascular shadowing, where the skin has become translucent enough that the underlying vessels and muscle show through as bluish or purplish darkness.
3. Fat pad herniation, where the fat pads behind the orbital septum^{4Orbital septumThin membrane separating the eyelid fat pads from the deeper eye socket.} push forward, creating a bag that casts a shadow beneath it.
4. Pigmentation, a dermal or epidermal discolouration that sits in the skin itself rather than being cast by a hollow.
5. Skin laxity and crepiness, where the skin has lost elasticity^{5Skin elasticityThe skin’s ability to spring back after stretching; declines with age and sun damage.} and become crepey, with fine wrinkles that deepen on animation.

Most clients have two or three of these simultaneously. The job of a good practitioner is to weight them correctly: is this person primarily a volume problem with a bit of vascular shadowing, or primarily a vascular problem with a bit of volume loss? The answer changes what we do first.

With that framework in place, let me walk through each tool in the modern toolkit, what it does, and where it fits.

Tool 1: Tear Trough Filler (Still the Right Answer, for the Right Patient)

I am not against tear trough filler. I perform it regularly, and when it is done well, on the right candidate, it remains one of the most transformative treatments I offer at Harley Street Injectables. A patient with genuine structural volume loss can walk in looking exhausted and walk out looking ten years more rested, in under thirty minutes.

The ideal tear trough filler candidate^{6CandidateA patient whose clinical presentation matches the treatment’s indications and safety profile.} is someone with:

• Clear structural hollowing as the dominant presentation
• Reasonable skin thickness and elasticity
• Adequate mid-face volume to support the correction
• Minimal puffiness or fluid retention
• Realistic expectations

The patients I steer firmly away from filler are those with:

• Prominent fat pad herniation (filling around a bag makes things worse)
• Very thin or crepey skin where the product will be visible
• A tendency toward facial oedema^{7OedemaFluid retention; swelling in the tissues, common in the thin under-eye skin.} or morning puffiness (hyaluronic acid attracts water)
• Primarily vascular darkness (filler does not correct this)
• Pigmentation (filler does not touch melanin-based darkness)

When filler is right, I use a cannula technique for the vast majority of tear trough treatments. A cannula is a blunt-tipped, flexible tube that glides through tissue rather than piercing it the way a sharp needle does. It significantly reduces bruising, and more importantly, it minimises the risk of vascular complications in an area that is densely vascular. We place the product deep, beneath the muscle, on the bone, where it provides structural support without creating superficial puffiness.

Product choice matters enormously. Not every hyaluronic acid filler is appropriate for under the eye. The products we use are specifically designed for delicate regions: soft, cohesive, low in water-attracting properties. Using a cheek or lip filler in the tear trough (something I have seen in corrective work more than once) produces visible ridges, bluish discolouration called the Tyndall effect^{8Tyndall effectA bluish tint under the skin caused by light scattering off superficially placed filler.}, and persistent swelling that can last months.

The bottom line on tear trough filler: still a brilliant treatment for the right candidate. Still the wrong treatment for the majority of patients who walk in asking for it.

Tool 2: Polynucleotides (The Treatment That Changed the Field)

If I had to pick the single most important addition to the under-eye toolkit in the last decade, it is polynucleotides^{9PolynucleotidesInjectable DNA fragments that regenerate skin from within.}.

Polynucleotides are purified DNA fragments, typically derived from salmon, that when injected into the dermis trigger a cascade of regenerative activity. They stimulate fibroblasts^{10FibroblastsThe cells in the dermis that produce collagen and elastin.} to produce new collagen and elastin. They improve microcirculation. They hydrate at a cellular level. And crucially, unlike filler, they do all of this without adding volume.

For the under-eye area specifically, this is revelatory. It means we can now treat the three presentations that filler was always wrong for (skin thinning, vascular shadowing, fine wrinkle crepiness) with a biological approach rather than a structural one.

The evidence base has matured quickly. A systematic review by Lampridou and colleagues (2025), published in Journal of Cosmetic Dermatology (lead author at Imperial College London), synthesised nine studies across 219 patients and concluded that polynucleotide injections show consistently promising outcomes in reducing wrinkles, improving skin texture, and enhancing elasticity, with statistically significant results across several studies and a favourable safety profile.

More importantly for this article, there is now a head-to-head randomized controlled trial comparing polynucleotides directly against hyaluronic acid filler in the periocular area. Lee and colleagues (2022), publishing in Journal of Dermatological Treatment, ran a split-face double-blind study on 27 subjects who received three injections at two-week intervals, with polynucleotides on one side and non-crosslinked hyaluronic acid on the other. Both products produced similar global aesthetic improvement scores. But over time, the polynucleotide side showed higher improvement rates in skin elasticity, hydration, roughness and pore volume compared to the HA side.

This is the key published evidence for what I have seen clinically. For under-eye presentations where the problem is skin quality rather than structural volume, polynucleotides are not just an alternative to filler. They are, on several measurable metrics, superior.

The ideal polynucleotide candidate is someone with:

• Thin, translucent skin with visible vascular shadowing
• Crepiness and fine wrinkles rather than a deep structural trough
• A history of puffiness or swelling with filler elsewhere
• Wanting genuine skin-quality improvement rather than a volumising effect
• The patience for a course of three to four sessions over six to twelve weeks

The treatment is not an overnight fix. Polynucleotides work gradually, with improvements building over weeks. The typical course is three sessions at three to four week intervals, followed by maintenance every six to nine months^{11MaintenancePeriodic top-up sessions to sustain treatment results long-term.}. Clients often describe the result as looking “brighter” or “more rested” rather than looking like they have had a treatment. That is, in my view, exactly the kind of result the under-eye area should aim for.

The bottom line on polynucleotides: the single most useful non-filler tool we have. For a significant proportion of patients who walk in asking for tear trough filler, polynucleotides are the better first step, either as an alternative or as the opening phase of a combined plan.

Tool 3: Skin Boosters (Profhilo and Skinvive)

Skin boosters are a category of injectable that sits somewhere between a traditional filler and a polynucleotide. They are hyaluronic-acid based, so they do provide some hydration and mild volumising, but they are formulated to behave more like a bio-stimulator than a structural filler, spreading through the tissue and supporting skin quality rather than projecting a specific area.

Profhilo is the best-known example in the UK. It uses an ultra-pure, highly concentrated hyaluronic acid in a hybrid of high and low molecular weights, which spreads through the dermis after injection and stimulates collagen and elastin production. It is not ideal for injecting directly into the tear trough itself (its spreading behaviour and water-attracting properties can create puffiness there), but it works well in the periorbital area more broadly, particularly over the upper cheek and temple where it improves the skin quality around the eye without adding volume in the tear trough zone specifically.

Skinvive by Juvéderm is a newer microdroplet hydrator that delivers modified hyaluronic acid^{12Modified HAHyaluronic acid chemically altered to last longer and behave more as a hydrator than a filler.} into the superficial dermis in a grid pattern. The effect is improved hydration, smoothness and a subtle glow. Like Profhilo, it is used around the eye rather than in the tear trough itself.

Skin boosters are a good option for:

• Improving overall periorbital skin quality alongside a filler or PN plan
• Clients who want an entry-level treatment before considering anything more targeted
• Anyone whose primary concern is skin dullness and dehydration rather than a specific structural deficit

They are not a substitute for tear trough filler when the issue is true structural volume loss, and they are not as targeted as polynucleotides for the specific problem of skin thinning and vascular shadowing. But as part of a combined plan, they are a useful adjunct.

Tool 4: Radiofrequency Tightening (Thermage FLX)

Here is where the conversation shifts from injectables to devices. For patients whose dominant presentation is crepiness, fine wrinkles, and laxity, the best tool may not be a syringe at all. It may be a radiofrequency device.

Thermage FLX delivers monopolar radiofrequency energy^{13Monopolar RFA radiofrequency device that heats the deeper dermis to stimulate collagen contraction and remodelling.} deep into the dermis, heating collagen fibres to the point where they contract and trigger a long-term wound-healing response that remodels the tissue over the following three to six months. The periorbital area is one of the original indications for this technology, and it is FDA-cleared for use on the eyelids specifically, a significant point of difference from many other skin-tightening modalities.

The evidence here is notably strong. The landmark multicenter study by Fitzpatrick and colleagues (2003) in Lasers in Surgery and Medicine treated 86 subjects with a single radiofrequency session and followed them for six months. Independent blinded scoring of photographs showed Fitzpatrick wrinkle score improvements of at least one point in 83.2% (99 of 119) of treated periorbital areas. Objective photographic analysis also demonstrated that 61.5% (40 of 65) of eyebrows lifted by at least 0.5mm. The 2nd-degree burn incidence, in an era of earlier device technology, was just 0.36%.

Subsequent iterations of the Thermage device have improved on this, with the current FLX system using larger tips, vibration for patient comfort, real-time impedance feedback, and integrated cooling.

Thermage is a strong option for:

• Visible crepiness, fine lines and mild-to-moderate laxity around the eye
• Patients who want a non-injectable approach or are needle-averse
• Patients with some fat pad descent where tightening the surrounding skin can support and camouflage the bag rather than needing to fill around it
• A treatment that complements injectables rather than competing with them

It is a single-session treatment with results that continue to improve for up to six months after the procedure, and the effect typically lasts 18 to 24 months. The trade-off is that it addresses skin quality and tightening rather than structural volume loss, so it is not a substitute for filler in a patient with a genuine trough.

The bottom line on Thermage: if your under-eye concern is skin texture, crepiness, or mild laxity rather than hollowness, Thermage is often a better starting point than any injectable. And if injectables are part of your longer-term plan, Thermage creates a better skin substrate for them to work on.

Tool 5: NeoGen Plasma

NeoGen Plasma uses nitrogen plasma energy rather than radiofrequency or laser. It delivers thermal energy to the skin surface and deeper dermis without vaporising tissue, triggering a similar remodelling response to other energy-based devices but with different characteristics. It has become a useful option in our periorbital toolkit for patients who need more textural improvement than Thermage alone provides, or whose presentation includes both laxity and sun damage or fine pigmentation.

NeoGen sits in a similar slot to Thermage in the decision framework, but the plasma mechanism lends itself better to cases where the surface texture (rather than just laxity) needs work. The downtime is a little longer than Thermage, typically five to seven days of peeling and redness, though still significantly less than an ablative laser.

It is a reasonable option for:

• Combined crepiness, mild pigmentation and laxity around the eye
• Patients who are willing to accept a few days of visible recovery in exchange for stronger textural improvement
• As part of a combined plan where Thermage alone has not gone far enough

Tool 6: Morpheus8 (Periorbital Applications)

Morpheus8 is radiofrequency microneedling^{14MicroneedlingTiny needles create controlled injury in the skin to stimulate collagen; Morpheus8 adds radiofrequency heat.}: micro-needles penetrate the skin to deliver radiofrequency energy at a controlled depth. It is not traditionally a first-line under-eye treatment because the area is so thin, but for selected presentations (particularly patients with textural concerns, acne-related scarring around the eye area, or moderate laxity who are not candidates for ablative laser) it has a place.

I use Morpheus8 periorbitally rather sparingly, and usually as part of a combined plan rather than as a standalone. It is a useful tool to have in the toolkit, not a first-line treatment for most under-eye presentations.

Tool 7: Surgical Referral (Knowing When to Say No)

This is the tool people expect a non-surgical clinic to leave off the list. I want to be explicit about why I am including it.

There are clients who walk into our clinic with under-eye concerns that, honestly, the non-surgical toolkit cannot adequately address. Severe fat pad herniation that has become a true lower-lid bag. Significant skin excess and festoons. Advanced ageing where the tissue simply needs to be re-draped rather than treated.

For those clients, the right answer is a referral for a consultation with a reputable oculoplastic surgeon^{15Oculoplastic surgeonA plastic surgeon specialising in procedures around the eyes.} to discuss lower blepharoplasty. I know that as the founder of a non-surgical clinic, recommending surgery seems counterproductive. But I would rather lose a client to a surgeon who can deliver the right outcome than keep them by giving them a wrong one. The whole point of a decision framework is that it includes the option of saying no.

The Decision Matrix

Here is a simple visual way to think through which tool is likely to fit your presentation.

Matching Presentation to Treatment

A simplified guide. Your actual plan should come from a consultation, since most clients present with a combination of concerns.

If your main concern is…	First-line tool	Supporting options
A genuine structural hollow. a defined groove that looks the same whether you have slept well or not	Tear trough filler (cannula, deep, conservative volume)	Cheek filler for mid-face support; polynucleotides to optimise skin quality first
Thin skin with vascular shadowing. bluish or purplish darkness, skin feels delicate, veins visible	Polynucleotides (course of 3)	Profhilo or Skinvive for general skin quality; Thermage if texture is also affected
Crepey, finely wrinkled skin. lines that deepen when you smile, texture looks papery	Thermage FLX	Polynucleotides; NeoGen Plasma if surface texture also needs work
Fat pad puffiness or bags. a visible bulge that casts its own shadow	Skin-tightening (Thermage) or surgical referral	NOT filler; polynucleotides can improve surrounding skin; NeoGen plasma in mild cases
True pigmentation. dermal darkness that doesn’t move with the light	Topical prescribing, skincare protocol, targeted energy-based treatments	NOT filler or polynucleotides in isolation
A combination presentation. two, three or more of the above layered together	Phased plan starting with polynucleotides	Reassess at 6–8 weeks; add filler, Thermage or Profhilo as required based on what remains

The matrix is a starting point, not a prescription. Most clients do not map neatly onto a single row. The purpose of the framework is to shift the conversation away from “should I get tear trough filler?” to a more useful question: “what is actually going on with my under-eye area, and given that, which of these tools, in what order, is likely to give me the best outcome?”

Example Pathways: How This Plays Out in Practice

It is easier to understand the framework with real scenarios. Here are four archetype clients I see regularly, and the plans I typically build for them.

Archetype 1: The Early-Thirties Professional with “Tired Eyes”

Presentation: mid-thirties, generally good skin, mild vascular shadowing, no structural hollow, occasional puffiness in the morning. Wants to look less tired in Zoom calls.

Plan: three sessions of polynucleotides at three-week intervals. Reassess at week 10. If any residual darkness, consider a very small amount of HA in the tear trough, but in most cases the PN course alone is sufficient. Annual maintenance thereafter.

Filler is wrong here because the darkness is vascular and the skin is thin. A syringe of filler would create puffiness on top of a shadow that would not have shifted. A course of polynucleotides thickens the skin enough to mask the underlying vasculature and improves microcirculation, which addresses the actual mechanism.

Archetype 2: The Client Who Has Had Filler Elsewhere and Wants It Dissolved

Presentation: forties, had tear trough filler twelve months ago at a different clinic, has developed a chronic puffy, heavy look to the lower lid. Sometimes worse in the morning. They know something is wrong but were told at the original clinic that “it is fine, it will settle.”

Plan: hyaluronidase^{16HyaluronidaseAn enzyme that dissolves hyaluronic acid filler, used to reverse bad outcomes.} to dissolve the existing filler, with a several-week interval to allow tissue to settle. Reassess. In most of these cases, once the product is removed, the underlying presentation is actually mild and the right treatment going forward is polynucleotides, not more filler. Some clients are so relieved by simply having the product removed that they do not want further intervention at all.

This is a common pathway. Filler that has been placed too superficially, or in too much volume, or in the wrong candidate, accumulates and distorts the area over time. The first step in correction is almost always removal, not more treatment.

Archetype 3: The Late-Forties Client with Genuine Structural Volume Loss

Presentation: late forties, visibly deeper tear trough than a decade ago, good skin quality overall, no puffiness, mid-face looks mildly deflated.

Plan: start with cheek filler to support the mid-face, often this alone reduces the apparent tear trough depth by 30–40%. Reassess at 4 weeks. If structural hollowing remains, conservative tear trough filler with cannula, deep placement, small volumes per side. Follow with a course of polynucleotides to optimise skin quality around the correction, so the filler integrates more naturally.

This is the classic case where filler is the right tool. But note: it is not usually the first intervention. Mid-face support often does more than the tear trough itself.

Archetype 4: The Client with “I’ve Tried Everything” Crepiness

Presentation: fifties, crepey skin around the eye, fine wrinkles that deepen on animation, has tried various skincare products and serums without meaningful change. No significant volume loss. Some mild laxity in the upper cheek.

Plan: Thermage FLX as the primary treatment, single session, with results continuing to improve over six months. Support with a course of polynucleotides starting four to six weeks after Thermage to optimise skin quality. Annual Thermage maintenance.

Injectables alone will not fix this presentation. The underlying issue is skin laxity and texture, which is what radiofrequency tightening was designed for. Starting with Thermage gives you the structural improvement that PN or filler alone cannot deliver.

Why the Consultation Matters More Than the Treatment

Reading this article, you have probably formed a working guess about which presentation you have. That is useful. It means you will arrive at consultation better informed, better able to have a productive conversation, and better placed to understand the recommendation.

But I want to be honest: almost every client I see thinks they know their presentation, and a significant minority of them are wrong.

The most common error is self-diagnosis as “structural hollowing” when the actual dominant presentation is vascular shadowing with a bit of fat pad prominence. The skin appears hollow because the vessels beneath are visible and the light falls into a shadow cast by the bag. Filling this does not work.

The second most common error is assuming that “dark circles” are pigmentation, when they are vascular. Or vice versa. These two require completely different treatments, and they look deceptively similar in the mirror.

The third is assuming the problem is isolated to the under-eye when it is actually a mid-face volume issue where the under-eye is just where the deficit is most visible.

A good consultation does several things that a blog post (even this one) cannot.

• Hands-on examination under clinical lighting, including gentle palpation to assess fat pad position and skin elasticity
• Dynamic assessment of how the area moves on animation, which reveals laxity and fat pad mobility
• Blanching tests to differentiate vascular darkness from pigmentation
• Photography under standardised lighting and angles, which reveals structural features invisible to the patient in everyday mirrors
• Context of the whole face, because the under-eye rarely operates in isolation from the cheek, brow, and temple

At Harley Street Injectables, the consultation is complimentary and deliberately unhurried. We often end a consultation with a recommendation to start with something less invasive than the client had expected, or, occasionally, with a recommendation to do nothing at all. Neither outcome is commercially optimal for a clinic in the short term. Both are, in my view, the correct clinical decision in the long term.

When to Worry: Red Flags in Under-Eye Treatment

Given that this article is partly about helping you avoid poor outcomes, let me be direct about the warning signs to watch for when considering under-eye treatment at any clinic, including ours.

• A practitioner who goes straight to a treatment recommendation without examining you. The consultation should take ten to twenty minutes minimum. If the answer is “tear trough filler” within the first two minutes, find somewhere else.
• A practitioner who does not discuss alternatives. If the only tool offered is filler, the practitioner either does not have the other tools or does not know when to use them.
• A practitioner who cannot explain why they are choosing one treatment over another. “This is what I do for dark circles” is not an answer. The answer should be “I see vascular shadowing here rather than structural hollowing, which is why I am recommending polynucleotides rather than filler.”
• Unrealistic promises. “You will walk out looking ten years younger” from a single syringe of filler is not medicine; it is marketing. The best outcomes are built over time with the right sequencing.
• Prices that seem low for the area. Tear trough treatment is one of the highest-skill procedures in non-surgical aesthetics. Pricing at budget levels usually indicates either inexperience or corner-cutting. Neither is something you want in the under-eye area.
• No emergency protocol. The under-eye area has proximity to the ophthalmic artery, and the catastrophic complication of tear trough filler (though rare) is blindness from vascular occlusion. Any clinic performing this treatment should have hyaluronidase on-site, trained protocols, and access to emergency ophthalmological support. If the clinic cannot clearly articulate their complication management, walk away.

The Combined-Plan Philosophy

Reading this article, you may have noticed a pattern. Almost every recommendation ends up being a combination rather than a single treatment. There is a reason for that.

The under-eye area has multiple layers (skin, dermis, muscle, fat, bone) and ageing affects all of them to different degrees in different people. A single treatment addresses one layer. A thoughtful plan addresses several, in the right sequence, with the right amount.

My typical under-eye plan for a client presenting with combined concerns looks like this.

Phase 1 (Skin Optimisation): polynucleotides, three sessions over six to nine weeks, to improve skin quality at the cellular level. Sometimes combined with Profhilo in the surrounding area.

Phase 2 (Reassessment): a dedicated review appointment six to eight weeks after the final PN session. How much has the skin quality improved? Has the apparent hollowing reduced? Is there still a structural deficit? Is the mid-face well supported? This is the step that most clinics skip, and skipping it is how over-treatment happens.

Phase 3 (Structural Correction if Needed): for the portion of clients who still have genuine structural hollowing after Phase 1, conservative tear trough filler with cannula, deep placement, small volumes. Often combined with cheek support to avoid filling the trough in isolation.

Phase 4 (Skin Tightening if Indicated): for clients with laxity or crepiness that was not fully addressed by Phases 1-3, add Thermage FLX, usually 4-6 months into the plan, allowing the previous treatments to settle first.

Phase 5 (Maintenance): polynucleotide top-ups every six to nine months, Thermage annually or biennially, filler refreshes as needed (with polynucleotide maintenance, the filler usually lasts longer than it would alone).

Not every client needs every phase. Some only need Phase 1. Some are classical Phase 3 candidates from the start. Some need a different framework entirely. The point is that the plan is built around the presentation, not the other way around.

What To Take Away From This Article

If you only remember one thing from 5,000 words on the under-eye area, remember this.

The question is not “should I get tear trough filler?” The question is “what is actually happening with my under-eye area, and given that, which of the available tools is the best first step?”

The answer for most patients is no longer filler. The answer is polynucleotides, or a skin-tightening device, or a skin booster, or simply mid-face support, or in some cases nothing beyond better skincare and a period of reassessment. And for the subset of patients where filler genuinely is the right answer, the question becomes: is it the only step, or the last step in a sequence?

Getting this right matters. The under-eye area is small, but it carries a disproportionate weight in how we read faces. When you get under-eye treatment right, people stop asking if you are tired. They do not comment on the treatment; they just register that something has shifted, and they interpret it as rest, energy, lightness. That is the result you are looking for.

If you would like to explore what makes sense for your specific presentation, we offer complimentary consultations at Harley Street Injectables. We will examine you, explain what we see, discuss the options, and give you an honest recommendation, which may be tear trough filler, or polynucleotides, or Thermage, or a combined plan, or a referral to a surgeon, or simply a period of reassessment. The conversation is where every good outcome starts.

If you have not yet read the companion piece on understanding under-eye hollowing, I would encourage you to do that first, since diagnosis is where everything begins. And if you want to read more about the specific alternatives to filler, our article on polynucleotides vs tear trough fillers is a useful starting point.

Glossary of Terms

Quick definitions for every clinical term marked in the article. Hover or tap a footnote number to see at a glance, or scroll here for the full list.

Candidate ↩︎

Patient whose presentation matches the treatment’s indications.

Fibroblasts ↩︎

Dermal cells that produce collagen and elastin.

Hyaluronidase ↩︎

Enzyme that dissolves hyaluronic acid filler.

Maintenance ↩︎

Top-up sessions to sustain treatment results long-term.

Microneedling ↩︎

Tiny needles creating controlled injury to stimulate collagen.

Modified HA ↩︎

Hyaluronic acid chemically altered for longer-lasting hydration.

Monopolar RF ↩︎

Radiofrequency that heats deep dermis for collagen remodelling.

Oedema ↩︎

Fluid retention causing swelling in the tissues.

Oculoplastic surgeon ↩︎

Plastic surgeon specialising in procedures around the eyes.

Orbital septum ↩︎

Membrane separating eyelid fat pads from deeper orbit.

PDRN/PN ↩︎

DNA fragments that stimulate skin’s regenerative cells.

Polynucleotides ↩︎

Injectable DNA fragments that regenerate skin from within.

Skin elasticity ↩︎

The skin’s ability to spring back after stretching.

Translucent skin ↩︎

Skin thin enough that vessels beneath show through.

Tyndall effect ↩︎

Bluish tint from light scattering off superficial filler.

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Alice Henshaw, RN, NMP, is the founder and medical director of Harley Street Injectables, the largest clinic on Harley Street dedicated exclusively to non-surgical aesthetic treatments. A qualified nurse prescriber registered in the UK, Australia, and New Zealand, Alice is a Key Opinion Leader for Allergan Aesthetics, was named Best Aesthetic Injector in London by the GHP Awards, and has been featured in Vogue, Tatler, Vanity Fair, and the Tatler Cosmetic Surgery Guide. The clinic is CQC registered and offers complimentary consultations with all treatments.

To book a consultation, visit harleystreetinjectables.com or call +44(0) 3455 485 658.

Sources referenced in this article:

1. Fitzpatrick, R., Geronemus, R., Goldberg, D., Kaminer, M., Kilmer, S., Ruiz-Esparza, J. (2003). “Multicenter study of noninvasive radiofrequency for periorbital tissue tightening.” Lasers in Surgery and Medicine, 33(4), 232-242. PMID: 14571447. DOI: 10.1002/lsm.10225. Landmark 86-subject multicenter study establishing periorbital RF efficacy.

2. Lampridou, S., Bassett, S., Cavallini, M., Christopoulos, G. (2025). “The Effectiveness of Polynucleotides in Esthetic Medicine: A Systematic Review.” Journal of Cosmetic Dermatology, 24(2), e16721. PMID: 39645667. DOI: 10.1111/jocd.16721. Imperial College London systematic review of 9 studies across 219 patients.

3. Lee, Y.J., Kim, H.T., Lee, Y.J., Paik, S.H., Moon, Y.S., Lee, W.J., Chang, S.E., Lee, M.W., Choi, J.H., Jung, J.M., Won, C.H. (2022). “Comparison of the effects of polynucleotide and hyaluronic acid fillers on periocular rejuvenation: a randomized, double-blind, split-face trial.” Journal of Dermatological Treatment, 33(1), 254-260. PMID: 32248707. DOI: 10.1080/09546634.2020.1748857. Head-to-head split-face RCT in the periocular area.

Further reading from Harley Street Injectables:

• A Practitioner’s Guide to Understanding and Treating Hollow Eyes, the diagnostic companion piece to this article.
• Polynucleotides vs. Tear Trough Fillers: Understanding Your Options, a shorter introduction to the two main injectable options.